Massage Intake Form Contact Information Name Street Address City State Zip Code Home Phone Work Phone Cell Phone E-mail Address Emergency Contacts Primary Physician Physician Phone Emergency Contact Name Emergency Contact Phone Emergency Contact Relationship Biometric & Health Information Age Occupation Recent injury or hospitalization? YesNo If yes, please explain Skin problems or allergies? YesNo If yes, please explain List any medications and their purpose List any supplements/vitamins/etc. Sports you engage in Current workout program Please check any conditions you previously experienced or are currently experiencing: emotional challengesfeverinsomniaheadachesallergiesobesitycancerchronic painsurgeryelevated cholesterolsports injurythrombophlebitisphlebitiscold viruscigarettesheart ailmentulcerated coloncirculatory problemsdiabetesosteoporosisdigestive disordersinfectious conditionsneck/spine injurydiverticulitisaccidental injuryappendicitisulcershigh blood pressureathritiswhiplashacute painback painTMJ syndromeconstipationfluepilepsykidney ailmentheart problemspregnancyvaricose veins Completion Were you Referred? YesNo If yes, By Whom? How did you find me? GoogleOther Search EngineTwitterFacebookLinkedInOther If "Other", please specify I understand that the massage therapy given here is for the purpose of stress and pain reduction, relief from muscular tension or spasm, and for increasing circulation and energy flow. I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. The massage therapist does not prescribe medical treatment or pharmaceuticals, or perform spinal manipulation. I understand that massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see an appropriate health care provider for any physical ailment that I might have. With this in mind, I agree to receive massage therapy and hold the therapist blameless for any problems that might arise as a result of the massage session. I have read and understand the above statement